Prospective Evaluation of a Ligature-Free Modified Peng Pancreatojejunostomy Reinforced with Blumgart Sutures in Patients with a Narrow Main Pancreatic Duct after Pancreaticoduodenectomy

Abstract Background or Purpose: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major complication after pancreaticoduodenectomy, particularly with a narrow main pancreatic duct (MPD ≤ 3 mm). We evaluated a ligature-free modification of Peng pancreatojejunostomy reinforced with Blumgart sutures. Methods This prospective single-center cohort included 160 consecutive patients undergoing pancreaticoduodenectomy at the National Cancer Institute, Cairo University, from December 2021 to December 2025. Eligibility required an MPD ≤ 3 mm on both magnetic resonance cholangiopancreatography and endoscopic ultrasound. The primary endpoint was CR-POPF (ISGPS Grade B/C, 2016 criteria). Results CR-POPF occurred in 10 patients (6.2%; exact 95% CI, 3.0–11.2%), all Grade B; no Grade C fistulae occurred. Overall morbidity was 23.1%, surgical-site infection 21.2%, and biliary leakage 1.2%. Median postoperative hospital stay was 7 days (range, 7–30). In exploratory analysis, CR-POPF occurred more frequently in patients with diabetes mellitus (15.8% vs 1.0%; Fisher’s exact P = 0.0004). Discussion or Conclusion: The modified technique was feasible and was associated with a 6.2% CR-POPF rate in this narrow-duct cohort. Because the study was single-arm and non-comparative, the findings do not establish efficacy, superiority, or non-inferiority. Comparative multicenter studies are warranted.